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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 13026A (02/08)

STATE OF WISCONSIN

BADGERCARE PLUS PREMIUM

Member / EMPLOYER ELECTRONIC FUNDS TRANSFER COMPLETION INSTRUCTIONS
BadgerCare Plus requires certain information to authorize and pay for medical services provided to enrolled members. Members are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information shall include but is not limited to information concerning enrollment status, accurate name, address, and identification number (HFS 104.02[4] Wis. Admin. Code). Under s .49.45(4), Wis. Stats., personally identifiable information about applicants and members is confidential and is used for purposes directly related to program administration such as payment of premiums by members. Failure to supply the information requested by the form may result in denial of payment for services. INSTRUCTIONS The Member/Employer Electronic Funds Transfer, HCF 13026, may be used by recipients who are making their own payments, as well as employers who are withholding payments on behalf of employees who have BadgerCare Plus. Fill out this form for BadgerCare Plus to automatically deduct funds from the checking or savings account the third of each month for the BadgerCare Plus premium payment. Should the third fall on a weekend or holiday, funds will be taken from the account the following business day. Employers must complete a separate form for each employee. To have funds taken out automatically, fill out the section of the form that says "Complete the information below": · Receiving Bank / Savings and Loan / Credit Union Enter the name of the bank, savings and loan, or credit union in the space. If it is a branch office, enter that information under "Branch." Include the city, state, and ZIP code where the bank, savings and loan, or credit union is located. Use the information for the branch visited most frequently. Account Type Check the box for the type of account, checking or savings, from which the funds should be taken. Bank Transit Routing Number and Bank Account Number These numbers can be found on the bottom of your checks and deposit slips. A voided check or deposit slip must be attached to the Electronic Funds Transfer (EFT) form. The bank transit routing number is the first nine digits. The following number, up to 17 digits in length, is the bank account number. Contact the bank, savings and loan, or credit union to clarify these numbers. Names(s) and Signature(s) Print the names of the account's owner and co-owner if it is a joint account. Enter the identification number of the person who is the case head or the person in charge of BadgerCare Plus for the family. Signature -- Employer If the recipient decides to pay the premium payment using employer wage withholding, and the employer chooses to pay using EFT, the employer will need to fill out and sign the EFT form.

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The account owner and account co-owner, if it is a joint account, then need to sign and date the form. If there are any questions regarding the above information, call 1-888-907-4455.

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 13026 (02/08)

STATE OF WISCONSIN

BADGERCARE PLUS PREMIUM

MEMBER / EMPLOYER ELECTRONIC FUNDS TRANSFER
INSTRUCTIONS: Type or print clearly. Before completing this form, read the Member/Employer Electronic Funds Transfer Completion Instructions, HCF 13026A. A voided check or deposit slip must be attached to this form for verification of correct information. Name(s) on Account BadgerCare Plus I give permission to BadgerCare Plus to begin taking money out of my (our) checking/savings account named below, at the bank/savings and loan/credit union named below. Complete the information below. Receiving Bank / Savings and Loan / Credit Union Branch

Address -- Bank / Savings and Loan / Credit Union (Street, City, State, ZIP Code)

Account Type:

Checking

Savings

Bank Transit Routing Number (Nine-Digit Number)

Bank Account Number (Maximum 17 Digits)

This permission is to remain in effect until BadgerCare Plus has received written notice from me (either of us) of its ending, in order to allow BadgerCare Plus and Firstar Bank a reasonable opportunity to act on it. If I lose my BadgerCare Plus eligibility, I understand my Electronic Funds Transfer will be ended. Name -- Account Owner Case Head Identification Number

SIGNATURE -- Account Owner

Date Signed

SIGNATURE -- Account Co-owner (If Applicable)

Date Signed

SIGNATURE -- Employer (If Applicable)

Date Signed

All written debt authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. DISTRIBUTION Mail completed form to the following address: BadgerCare Plus Cash/Premium Unit PO Box 6648 Madison WI 53716-0648 Telephone: 1-888-907-4455 Fax: 1-608-251-1513

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